Comprehensive Psychiatric Evaluation-31-year-old male

Comprehensive Psychiatric Evaluation-31-year-old male

Patient Initials: M.K.

Age: 31 years

Gender: Male

Race: African American

Subjective:

CC (Chief Complaint): Suicide attempt.

History of Present Illness (HPI): M.K. is a 31-year-old African American male brought to the emergency department by his sister after a failed suicide attempt. M.K.’s sister reports that she found M.K. lying on the floor unconscious, with an empty pack of pesticides next to him. She highlights that M.K. was unresponsive; therefore, she rushed him to the hospital emergency unit. M.K.’s sister narrates that she began noticing changes in M.K.’s mood and behavior three months ago when he lost his job and broke up with his girlfriend. The two events occurred in the same week; since then, M.K. has seemed hopeless and does not sleep. M.K. has mentioned to a few family members that he is ready to die. He has gone to the extent of explaining how he would like to be buried. M.K. received emergency care since he was unconscious and unresponsive.

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Past Psychiatric History: M.K. was first diagnosed with major depressive disorder one month ago. He is monitored closely by a caregiver during the day. In the evening and night, he is monitored by his sister. He was hospitalized for monitoring once one month ago after a failed suicide attempt. His current treatment plan for major depressive disorder involves non-pharmacological therapy through psychotherapy. He has not been prescribed any medication, as his progress with psychotherapy has been observed. He currently visits his psychiatrist once a week.

Substance Use History: M.K. reports that he smokes about one pack of cigarettes every two weeks and occasionally drinks alcohol. He describes his intake of alcohol as being “a social drinker.”

Family Psychiatric/Substance Use History: M.K.’s mother has had a history of depression and suicidal ideation since she was a teenager. She, however, has successfully managed her condition by being compliant with her treatment plan. M.K. is not aware of any mental health problems within the extended family. Notably, M.K. describes his father as an occasional drinker of alcohol and his sister as a staunch Christian who uses no recreational drugs.

Social History: M.K. was born in New York and was brought up by his father and mother. He is the last born of two children. His elder sister is 39 years old. M.K. lives in a three-bedroom apartment with his sister. He is divorced, and his girlfriend broke up with him three months ago. M.K. has a daughter who lives with his ex-wife in another city. He holds a master’s in economics and worked as a lecturer at a nearby university. Losing his job was traumatizing since he enjoys teaching and believes in the impact of empowering the younger generations. He is currently unemployed. M.K. is a good citizen who respects the law and has never had any legal history apart from his divorce trial. Before his major depression, he enjoyed playing golf with his friends and colleagues.

Past Medical History (PMH): M.K. was diagnosed with asthma when he was five years old, which he manages using oral prednisone. He was diagnosed with a major depressive disorder one month ago. His immunization status is up to date. He received two doses of the AstraZeneca vaccine for COVID-19 in August and September 2021.

Current Medications: Prednisone 5mg BD PRN.

Allergies: No known drug allergy. Lactose intolerance.

Reproductive history: Heterosexual.

ROS:

General: Reports daytime sleepiness and headache. Denies chills, fever, day sweats, fatigue, weight loss, or weight gain.

HEENT/Neck: Reports rhinorrhea and blurred vision. Denies oral, hearing, and dental problems.

Skin: Denies rashes and itching.

Cardiovascular: Denies chest pains, lightheadedness, numb extremities, paroxysmal nocturnal dyspnea, leg edema, slow wound healing, palpitations, arrhythmias, dyspnea, slow wound healing, or orthopnea.

Respiratory: Reports cough and difficulty breathing. Denies choking when swallowing, shortness of breath, holding breath during sleep, wheezing, or sputum production.

Gastrointestinal: Reports diarrhea, abdominal pain, vomiting, hypersalivation, and nausea. Denies indigestion, heartburn, choking during sleep, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies urinary incontinence, painful urination, decreased stream, frequent urination, dribbling, and blood in the urine.

Neurological: Reports loss of consciousness, headache, and confusion. Denies changes in memory, memory loss, seizures, difficulty balancing, numbness, tingling sensation, spells of blindness,  or dizziness.

Musculoskeletal: Reports tremors. Denies stiffness and muscle, joint, and back pain.

Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.

Lymphatics: Denies swollen lymph nodes or splenectomy.

Endocrinology: Denies weight gain, weight loss, hair loss, hot flashes, and frequent urination.

Psychiatric: Positive history of major depressive disorder. Reports a history of suicidal thoughts and ideation. M.K. has been brought to the hospital after a failed suicide attempt. He is currently undergoing psychotherapy for major depressive disorder.

Objective:

Physical Exam:

Vital signs: BP 89/59 mmHg, HR-80 bpm, SPO2- 97% on room air, Temp 97.2, RR-16 bpm, Height- 5’8, Weight- 163lbs, BMI 24.7.

General: The patient appears confused and disoriented. He is not fully aware of his surroundings. He is hygienic and well-dressed.

HEENT: Clear or nasopharynx, PERRLA, normocephalic head, miosis.

Neck: Neck has normal symmetry, no palpable lymph nodes, a full range of motion, and normal length.

Respiratory: No tenderness or palpable mass, no chest deformities, faint breath sounds without wheezing.

Heart/Peripheral Vascular: Normal heart size, normal heart rate, normal heart location, no murmurs, and normal rhythm. Normal extremities.

Abdomen: Abdominal pain. The liver and spleen are of normal size, consistency, and tenderness.

Genital/Rectal: This exam was not conducted.

Lymphatic: No swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological:  Intact deep tendon reflexes and cranial nerves.

Psychiatric: He is confused, disoriented, and unaware of the context.

Skin: His skin tone is appropriate to his ethnicity.

Diagnostic results:

Complete blood count: To test RBC levels to determine the extent of organophosphate poisoning.

Substance and alcohol screening: To rule out drug-induced depression symptoms.

RBC AChE blood test: Recommended and blood drawn before pralidoxime administration to determine organophosphate poisoning. Conducted after treatment to determine response to therapy (Robb & Baker, 2022).

Assessment:

Mental Status Examination: The patient is a 31-year-old African American male who looks his stated age. He appears confused and disoriented after a failed suicide attempt using a pesticide. During the session, he appeared to be in low spirits and did not laugh or smile. The patient started having suicidal thoughts and ideation three months ago after losing his job and breaking up with his girlfriend simultaneously. He highlights that he is feeling hopeless due to joblessness and being single. He is unlucky in love as a divorcee whose current relationship is over. His sister and other family members had been concerned about his tales of how he would like to be buried. He was diagnosed with a major depressive disorder, which he manages using psychotherapy. The mental status examination recognizes that confusion and disorientation are caused by organophosphate poisoning.

Differential Diagnosis (DDx):

Major depressive disorder: According to DSM-5 criteria, patients diagnosed with major depressive disorder present with at least five of the following symptoms in at least a two-week duration: depressed mood, psychomotor agitation, feeling worthless, loss of interest in activities, changes in weight and appetite, sleep disturbance, loss of energy, decreased ability to concentrate, and recurrent suicidal ideation, thoughts, and attempts. DSM-5 highlights that a depressed mood must be seen in a major depressive disorder patient (Bains & Abdijadid, 2022). M.K. has a history of major depressive disorder, suicidal ideation, and suicidal attempts. Additionally, he presents with more than 5 of the outlined symptoms (7 symptoms), which have lasted for three months: insomnia, failed suicide attempt, feeling hopeless, loss of interest in activities such as playing golf and hanging with other people, decreased ability to concentrate, feeling hopeless and worthless and having a depressed mood. Major depressive disorder is the primary diagnosis because of the seven signs and symptoms that have lasted for more than two weeks (three months) seen in the patient and the patient’s psychiatric history.

Bipolar disorder: Patients diagnosed with bipolar disorder experience periods of mania that alternate with periods of depressive mood. DSM-5 outlines that bipolar disorder presents with manic episodes for at least one week and at least three of the criteria signs and symptoms: excess pleasure in activities, grandiosity, decreased need for sleep, distraction, racing thoughts, excessive talking, and increased goal-focused activity (Jain & Mitra, 2022). Bipolar disorder is a differential diagnosis because M.K. presents with a depressed mood and insomnia. However, Before the depressed period, the explained character of M.K. does not show a manic period.

Dysthymic disorder: The DSM-5 criteria for dysthymic disorder include a depressed mood for at least two years in adults. The patient must present with at least two of the following: low self-esteem, hopelessness, low energy, changes in appetite, sleep disorders, and poor concentration (Patel & Rose, 2022). Dysthymic disorder is a differential diagnosis because M.K. presents with a depressed mood that includes insomnia, hopelessness, and poor concentration. Although M.K. has a depressed mood, he has experienced it for about three months only and not two years which is required to diagnose the dysthymic disorder in adults.

Reflections: I concur with M.K.’s assessment and diagnostic impression. M.K. is currently unemployed, which might affect his financial ability to obtain psychotherapy services. Although M.K. has emotional support from his sister and other family members, it is crucial to assess the views on mental health among African Americans. M.K.’s diagnosis of major depressive disorder is currently managed through psychotherapy. Since M.K. has had a failed suicide attempt while continuing with psychotherapy, I would include antidepressants such as SSRIs in his therapy. I would also ensure M.K. is adequately managed for organophosphate poisoning. I would refer M.K. to a rehab facility for advice on the negative impacts of cigarettes and alcohol on his condition. In addition, I learned the importance of having a caregiver monitor patients experiencing suicidal ideation. Further, the patient’s legal rights were respected by M.K., who was given a chance to understand his diagnosis and treatment plan. M.K. is considered a danger to himself; therefore, his sister was involved in the consenting process.

References

Bains, N., & Abdijadid, S. (2022). Major Depressive Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/.

Jain, A., & Mitra, P. (2022). Bipolar Affective Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558998/.

Patel, R. K., & Rose, G. M. (2022). Persistent Depressive Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541052/.

Robb, E. L., & Baker, M. B. (2022). Organophosphate Toxicity. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470430/.

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Diagnostic results:

Assessment

Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

Mental Status Examination:

Differential Diagnoses:

Reflections:

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

 References

Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.